Electronic cigarettes—The primary care provider's response

When considering e-cigarettes, clinicians should take patient circumstances into account.

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How should the primary care provider (PCP) respond to the new interest in electronic cigarettes? Is this a healthier way to provide a nicotine fix? Are the risk factors associated with traditional cigarette smoke the same with electronic cigarette smoke? The electronic cigarette is advertised in print and on TV, radio, and the internet as a healthier way to smoke. Many smokers have reported using electronic cigarettes for smoking cessation. However, little research has been completed to validate these claims. Fewer than 10 reported research studies have examined the effects of electronic cigarettes on various body systems.

This article reviews the current research available and provides evidenced-based guidance for how a PCP should respond to the growing number of smoking patients inquiring about the electronic cigarette's use as a potential way to improve their health. Smoking prevalence with traditional cigarettes in the United States remains high, despite a noted decline from 20.9% of the total population in 2005 to 19.3% in 2010.1 According to the CDC, approximately one in five adults, or 45.3 million people, in the United States smoke traditional tobacco cigarettes.1 The American Heart Association reported that smoking costs the U.S. economy $289 billion annually.2 PCPs often see patients for smoking-related diseases due to the cigarette smoker's rapid destruction of lungs, blood vessels, and body cells. Encouraging the cessation of smoking at every office visit, the PCP will frequently discuss options for smoking cessation. The newest challenge is responding to the inquiries related to electronic cigarettes as a means of health improvement and smoking cessation. This article outlines the history of e-cigarette development and use in the United States, the state of the evidence on e-cigarette use, quality control, and user reported benefits.

The popularity of e-cigarettes has been increasing since they first came on the market in 2004. George H. Gilbert patented the smokeless nontobacco cigarette in the United States in 1965.2 This product was not commercialized and disappeared until a Chinese pharmacist, Hon Lik, developed and patented his own electronic cigarette in 2003.3 The e-cigarette was then launched by the Ruyan Group Ltd in Beijing.4 An estimated 466 brands are available.2 A recent 2010-2011 health styles survey found that one in five current smokers have reported using electronic cigarettes.5 Wells Fargo predicted that sales for electronic cigarettes will grow to $10 billion dollars by 2017.2 As their popularity has grown, so has their availability. Now e-cigarettes are easily purchased at local gas stations and grocery stores and ordered over the internet. The brand Blu reports selling e-cigarettes in more than 100,000 retail stores.6 Advertising draws traditional smokers with claims that e-cigarettes look and feel more like traditional cigarettes, they are less expensive, and there is no ash, tar, secondhand smoke, or smell.7 Electronic cigarettes also come in various flavors and nicotine levels, which is an additional attraction for those looking to control their nicotine intake.7

Mechanics of e-cigarettes

The electronic cigarette is known as an Electronic Nicotine Delivery Device (ENDD). It is composed of a battery, automatic sensor, heating element (atomizer), and a cartridge of liquid nicotine solution. The nicotine solution is a combination of water, nicotine, propylene glycol, and flavoring.8 During inhalation, the airflow is detected by a sensor that activates the heating device. The heating device then vaporizes the nicotine solution enclosed in the cartridge in the mouthpiece. This process produces a vapor mist that resembles smoke.9 Instead of smoking, the use of electronic cigarettes is referred to as vaping.8

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